Prevention of mother to child transmission Program overview
Prevention of Mother to Child Transmission (PMTCT) programs implemented with the aim to prevent and even eliminate mother to child transmission of HIV and syphilis in the country. PMTCT of HIV is an important intervention in the prevention of HIV among children. In the absence of PMTCT interventions, transmission rate of HIV from mother to their children ranges from 15% to 45%. However, this rate can be reduced to below 5% with effective interventions during the periods of pregnancy, labor, delivery and breastfeeding. To achieve the National goal of eliminating mother to child transmission of HIV and syphilis, strengthening PMTCT program and decreasing cascade loss by providing comprehensive PMTCT interventions is necessary.
The Ministry of Health (MOH) endorsed Option B+ in August 2012 as an approach to avert new pediatric HIV infections and improve the survival of mothers and their babies. By December 2013, most sites across the country have introduced Option B+ (Test and treat). Access and utilization of PMTCT services is also expanded to 2865 health facilities in the country (84% of public facilities offer PMTCT services, but only 5% of privates). Rural facilities have highest percentage (59%) of facilities that offer PMTCT services (SARA, 2018 report). To prevent the transmission of HIV and syphilis from mother to child, all mothers are expected to have HIV and syphilis testing during ANC visit. Nationally, there were 24,641 estimated HIV positive mothers in 2018/2019 of which 73% mothers received ARV. From the total mothers, 38% of them were newly diagnosed in the fiscal year and the remaining, 62% were known HIV positive and linked to PMTCT. About 65.6% of HIV exposed infants received HIV test within 12 months and 46.1% of HEI received ARV prophylaxis (MOH, 2019). The proportion of HIV positive pregnant and lactating women who received Antiretroviral Treatment (ART) to prevent MTCT of HIV and the proportion of infants born to HIV-positive women receiving virological testing for HIV also show good progress. Overall, the proportion of infants born to HIV positive mothers who received ARV prophylaxis needs much effort. The estimated MTCT rate for 2019 is 16.9% (UNAIDS, 2020). This also shows the country is not on track to achieve virtual elimination.
Figure 1: Testing for syphilis among pregnant and lactating women – DHIS2
Figure 2: Testing for HIV among pregnant and lactating women – DHIS2
Source: UNAIDS report
Figure 3: Estimated HIV MTCT rate from 2014 to 2019
To achieve the national goal of EMTCT of HIV and syphilis the PMTCT program is lead major initiatives. Some of the initiatives that have been implemented to improve quality and access of PMTCT services are:-
- Mother baby cohort analysis
- PMTCT mentorship. Continuous quality improvement (CQI) and dashboard
- Enhanced postnatal prophylaxis (Dual prophylaxis for HEI)
- Point of care testing (POC) for Early infant diagnosis (EID)
PMTCT cohort monitoring (Mother baby cohort analysis)
Mother-Baby Pair Cohort follow up (Integrated PMTCT/MNCH) register is a monitoring and evaluation mechanism that helps to strengthen implementation of Option B+ recommendations in all MNCH platforms in an integrated manner. The HIV positive mother and her child are followed as a pair. Measuring the outcomes of HIV-infected mothers and their HIV exposed infants are necessary to evaluate and monitor the quality and impact of PMTCT programs. Maternal cohort analysis helps to monitor the retention of HIV-infected women enrolled in PMTCT programs in its facilities. Pregnant/breastfeeding women in the facility PMTCT program will be followed and monitored in groups or cohorts based on the month and year of their enrollment in the PMTCT program. PMTCT cohort monitoring is used to measure the PMTCT intervention outcomes through longitudinal approach using cohort monitoring tools. The Important PMTCT outcomes are:
- Final status of HIV-exposed infant (most importantly, HIV negative or Positive)
- Maternal retention on ART (or viral suppression)
- Other PMTCT outcomes: DNA PCR test collected (Early Infant Diagnosis) by age 2 months
PMTCT mentorship, Continuous quality improvement (CQI) and dashboard
Successful implementation of the EMTCT strategic plan will require continuous monitoring of PMTCT implementation and strong mentorship to improve the quality of PMTCT service and to decrease cascade care loss. To provide quality PMTCT services and comprehensive intervention package by clinical mentoring using standard checklist, CQI and dash board. Despite the increasing trend in PMTCT coverage, the program has not achieved its goals and needs to be strengthened by clinical mentoring.
Enhanced postnatal prophylaxis (Dual prophylaxis for HEI)
Previous WHO guidelines have acknowledged that when maternal ART is started late in pregnancy, during labor or in the postpartum period, infants who are breastfeeding may not be adequately protected from HIV because it takes several weeks for maternal viral load to be suppressed. In such situations, programs were advised to consider increasing the duration of infant prophylaxis to 12 weeks rather than 6 weeks of NVP. Since that time, new data have become available, showing that combination infant prophylaxis is more effective than single-drug prophylaxis for the prevention of mother-to-child transmission in infants born to mothers who have not received antepartum ARV drugs. To implement the new recommendation in Ethiopia, key areas (risk stratification, regimens and formulation and programmatic considerations) were assessed from different implemented countries. Hence, the country chose to consider all HIV exposed infant as a high risk and recommend ePNP for all HIV exposed infants and the chosen approach includes 6 weeks of AZT & NVP dual therapy, followed by a 6 weeks more of NVP alone.
Point of care testing (POC) for Early Infant Diagnosis (EID)
Infants acquire HIV most commonly through MTCT during pregnancy, labor and delivery or breastfeeding. Owing to the rapid progression of HIIV in infants, early infant diagnosis (EID) remains to be the hallmark to insure infant survival. EID is essential for timely initiation of ART and reducing the high morbidity and mortality that occurs in HIV infected children. Point-of-care (POC) testing for Early Infant Diagnosis (EID) of HIV has the potential to dramatically improve the efficiency of determining HIV status and reduce HIV-related morbidity and mortality in infants born to HIV-positive mothers. POC devices allow for rapid testing of infant blood specimens at the point of service, rather than sending samples to central laboratories for conventional EID testing.